Kantor & Kantor is happy to announce that it has won an important victory in New Jersey on behalf of a client with bulimia nervosa. The decision touches upon issues that we see too often in health insurance denials and long-term disability denials.
Our client, whose name is being kept anonymous to protect her privacy, began experiencing symptoms of her eating disorder when she was only eight years old. The eating disorder was left untreated for ten years. When she entered a residential treatment facility for her bulimia in September 2011, the facility submitted a claim for benefits to her insurance company, Horizon Blue Cross Blue Shield of New Jersey.
In a series of concurrent reviews, Horizon and its behavioral health managed care partner, Magellan Behavioral Health, paid for the first three weeks of treatment, but refused to pay past that date, contending that the treatment she was receiving was no longer “medically necessary.”
Kantor & Kantor filed several internal appeals and appeared before the State of New Jersey State Health Benefits Commission in support of our client’s appeal. After many years, Kantor & Kantor was able to present the case during an evidentiary hearing to an Administrative Law Judge at the New Jersey Office of Administrative Law. Just recently, Kantor & Kantor received a ruling from the court fully in our client’s favor. The Judge entered several important findings.
First, the Judge found that the opinions of the treating physicians at the treatment facility were entitled to greater weight as opposed to physicians who are employed by insurance companies for the mere purpose of making administrative decisions without any personal examination of the insured.
Second, the Judge found that Magellan’s utilization review and coverage determinations were “perfunctory at best, and wholly failed to take into account the treating team’s on-the-ground medical opinion…” The Judge concluded that Magellan inaccurately applied their own Medical Necessity Criteria and stated that Magellan’s “one (skimpy)-size-fits-all approach” is “patently absurd and in-credible.”
In conclusion, the Judge ruled that Magellan’s decision was wrong. The Judge found that our client met both the Magellan Medical Necessity Criteria and the APA Guidelines at the time her claim was denied and throughout the remainder of her residential treatment, which lasted until March 2012. As a result, the court reversed the denial of benefits and ordered Magellan to pay the outstanding claim in full.
There are many individuals who are battling with their insurers over health insurance denials and long term disability benefits. If you or someone you know needs help, please contact Kantor & Kantor at 877-783-8686.